Provider Demographics
NPI:1104386614
Name:PHILLIPS, JORDAN (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OGLETHORPE AVE STE C7
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2221
Mailing Address - Country:US
Mailing Address - Phone:706-266-7765
Mailing Address - Fax:
Practice Address - Street 1:700 OGLETHORPE AVE STE C7
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2221
Practice Address - Country:US
Practice Address - Phone:706-425-9445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02070207Q00000X
390200000X
GA99863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program